Abstract
Björn Salomonsson’s Psychoanalytic Therapy with Infants and Parents is a unique contribution to the modern literature on parent-infant psychotherapy, with a purview that is wide and ambitious in its range and scholarship. Salomonsson has set out to excavate the archaeology of early infant representations, the more negative of which can transform into lifelong inchoate affective fault lines if subject to “primal repression”; this repression, different from that we associate with unconscious conflict, is a Freudian concept he revives, elaborates upon, and suggests will inevitably occur absent the kind of early psychoanalytic intervention he delineates. The book, dense and scholarly, is replete with unusual examples of the author’s targeted psychoanalytic approach to parent-infant psychotherapy, which he argues is not simply a technique but also a means of understanding the formation of an infant’s mind; the approach itself is an investigative tool. All of this places the book in a category of its own. The work is an unusual hybrid: both casebook and scholarly review, blazing a trail into a novel therapeutic and hermeneutic frontier. Throughout this deceptively slim but theoretically dense volume, Salomonsson not only shares excerpts from his clinical cases, but simultaneously shuttles between the realms of classical and contemporary psychoanalytic theory, as well as infancy research and semiotics. He is hard at work, striving to create a unified theory of the earliest infant representations, which he suggests are best unearthed and understood as they arise in statu nascendi within a clinical practice of psychoanalytic parent-infant psychotherapy.
Though he has written many articles on infancy going back to 1989, this is Salomonsson’s first published book. It is not a collection of papers per se, but it does interweave material published previously into the text; this may explain the book’s frequent recapitulation, thematic redundancy, and occasional lack of fluidity. That said, given the density of Salomonsson’s writing and theory building, it is actually helpful to cycle through slightly different perspectives on the same material. The book makes a powerful argument for a psychoanalytic approach being the royal road, as it were, for understanding, treating, and learning from early distress in parent-infant dyads. Salomonsson implies that through such an approach with very young children and their caregivers, a clinician can be privy to the formation, quite literally, of the infantile unconscious.
Salomonsson is Swedish (though the book is written in English), a psychiatrist and psychoanalyst. He is known for his depth of experience and practice working with parent-infant dyads. He does this in both private and public settings, and is also a researcher in mother-infant psychotherapy (he refers to it as MIP) at the Karolinska Institute. Interestingly, the last chapter of the book reports the results of an impressively large randomized controlled study of this treatment that was spearheaded by Salomonsson. Though the field of parent-infant psychotherapy has been growing both abroad and in North America, it has tended to attract clinicians who either specifically choose to work or train in this specialty, or those working in settings with very young children and parents, in which early relational issues can be optimally addressed in the context of dyadic treatment.
Implicitly, the book suggests that knowledge gleaned from working with the earliest dyads can help us operationalize and give clinical support to aspects of theory that are already foundational in our psychoanalytic armamentarium. Salomonsson cites Freud’s Project for a Scientific Psychology several times throughout the book, perhaps by way of identification; he too is interested in creating an integrative, developmentally based theory of the unconscious that emerges from work with infants whose neurobiology and psychology initially evolve in tandem and in the context of their early relationships. His hypothesis is “that neither infant research alone—nor observations nor reconstructions in adult analysis alone—will render a full picture of infant mental phenomena. We must also take into account the baby in psychoanalytically oriented parent-infant treatments” (p. 24).
This idea was supported by cases he worked with, such as a two-week-old baby who habitually refused one breast, due to a wound on the mother’s breast that was quickly treated and then resolved. Even after the breast had healed, the infant continued to refuse that side. Salomonsson suggests that the baby’s continued refusal indicated the presence of a primordial representation, a mnemic trace of something unpleasurable, which then got taken up in the ongoing feeding situation with his mother, sustained perhaps within the baby’s dawning consciousness as a negative representation.
Such cases lend support to Freud’s theory of the axis of pleasure vs. unpleasure, suggesting to Salomonsson that the earliest representations emerge on that spectrum. Speculative of course, but no more so than theory itself (an in vivo example of the Kleinian good and bad breast?). Salomonsson is, after all, speaking to us from the front lines of in-depth psychoanalytic immersion with the newest of humans and their caregivers. Few of us in this field, even those with decades of clinical experience, can claim to have spent much time as clinicians within this inner sanctum of the parent-infant relationship, not to mention refracting it through the depths of a psychoanalytic lens that considers both mother and baby as separate but equal patients.
Most psychoanalytically trained clinicians today are by now conversant with the work of Beebe, Tronick, and Stern, among others, and are intellectually aware of the revolution that has taken place in our field, related to developmental and relational information gleaned from direct observation of infants and small children, often through the medium of video microanalysis. In addition, many analysts are aware of the field of infant observation following the tradition of Esther Bick. In fact, it has become a cornerstone of training, first in England and now more widely, for many who have chosen to work with parents and young children. And yet, analysts who have not been trained in direct encounters with mother-baby pairs, or who do not have experience with very young children, are unlikely to apply much from that field to their own work or to understand the potential benefit of applying a parent-infant model when considering adult patients.
Salomonsson is attempting to bring this relatively restricted knowledge and experience out of his consulting room and into the more general framework of psychoanalytic thinking. Arguing for its wider applicability, he is working to provide a robust clinical backdrop to many of the central assumptions that undergird classical theory. His work is important in that he takes on the question of how babies create their earliest preverbal representations and considers the fate of those representations once words come on board. His clinical practice comes out of a commitment to working with young babies and parents before that happens, and before some of these early negative representations become “living fossils,” less amenable to treatment (p. 111). His book interpolates this clinical work with extensive psychoanalytic scholarship.
He impresses, one might say dazzles, and at times overwhelms the reader with the wide-ranging breadth of his knowledge of psychoanalytic literature from classical to modern, as well as of semiotics and the literature on infancy research and treatment. His attempts to integrate and apply this multimodal theory in presenting clinical examples and vignettes are thoroughgoing and can occasionally leave the reader feeling exhausted by the voluminousness of his references. His bibliography alone runs fifteen pages. The book strives to demonstrate the ways our earliest affective experiences are encoded to form the armature that underlies linguistic, symbolic, and emotional development. Salomonsson is trying to show, it seems, how we can bear witness to (and alter) the origins of representation as we participate therapeutically with a parent-infant pair. A psychoanalytic attitude, he believes, can give us the means to rejigger what has gone wrong in even the earliest of dyads both synergistically and individually. He feels that parent-infant psychoanalytic treatment affords the clinician “an additional investigatory instrument” (p. 16) that can supplement (and to some degree provide evidence for) our psychoanalytic practice, demonstrating the process of “primal representation” in statu nascendi.
In other words, it is Salomonsson’s belief that a baby suffers when its primary caregiver cannot contain her own depression, ambivalence, or confusion and becomes alienated from the baby’s proto-communications. Suggesting that infants have a capacity to represent something in pictographic traces in their dawning minds, Salomonsson asserts that a “baby’s discombobulated pictograms correspond to a mother’s unconscious ambivalence towards her child” (p. 27). Without an analytically trained clinician to both witness and contain what starts out as an early relational issue (not at all uncommon), this parental ambivalence can become part of an inchoate infantile structure that can form a fault line below later developmental achievements, leading to mysterious “echoes” that remain unmetabolized, hovering beneath and beyond linguistic or symbolic reach.
So what is it that Salomonsson actually does in his consulting room? At first glance, it seems quite simple. Deceptively so, since what he is doing is in fact complex and hardly the stuff of parent guidance books or even familiar iterations of parent-infant psychotherapy. He wants to help with “baby worries”: issues that can crop up quite typically in the first year of life, starting in the first weeks and months. He feels that one can set up a psychoanalytic situation by seeing a parent-infant pair in regular sessions, up to four times weekly, when the parent is amenable. Distressed mothers (and at times fathers) and their babies are his patients. But the emphasis is on “and.” He addresses both mother and baby, taking their separate phenomenologies into account. Problems with maternal depression, breast feeding, fussing, excessive crying, disturbed sleep, infant gaze, and parental ambivalence and anxiety are his bread and butter. He sees this kind of work as necessary and preventive for the patients, as well as providing a tool for understanding the preverbal mind and earliest infantile representations.
Eschewing the usual attitude in psychoanalytically oriented parent-infant treatments (which includes a strong focus on the mother’s distorted representations and attributions regarding her baby and herself), Salomonsson sees the infant, no matter how young, as a patient in his or her own right, capable of transference to the analyst and capable of eliciting countertransference in turn. Just as Salomonsson addresses the parent, so too does he address the infant. Though Salomonsson makes no pretense that the baby understands him at a “lexical” level, his mode of address resonates from his affective response to the infant, drawing not on consensual linguistic meanings but principally on “the emotional wave-lengths” (p. 54) of words, which he uses to contain preverbal affects (arising from the baby but resonating within mother and analyst due to their own preverbal substrate) that may be related to the trouble at hand. According to Salomonsson, entering a dyad at the level of the earliest perturbations conceivably affords the best chance of transforming them before they can undergo primal repression. Once that happens, these early disturbances remain alive within the adult mind but are inaccessible to consciousness: “living fossils,” they embody unformulated pain and suffering.
It must be said that many of the clinical examples Salomonsson offers tend to boggle the imagination, involving as they do a mode of direct address to infants as young as a few weeks old. This can certainly seem like hocus-pocus, as if, as Salomonsson himself points out, he were succumbing to what Stern calls “adultomorphism” or were acting in a way Fonagy would consider “outside the developmental timetable.” He knows he risks being viewed as indulging in a Melanie Klein–like developmental fallacy. Yet throughout the book, Salomonsson takes pains to anticipate the reader’s skepticism and takes up the arguments that initially come to mind when we see him talking to the baby as to a “patient.” He attempts to take us into his own internal process and walks us through his thinking about his interventions, which he knows to be metaphors but considers mutative. Anticipating where we will scratch our heads in disbelief, he is quick to provide a sophisticated and preemptive critique of his own work.
One needs to take a deep breath and to some degree suspend one’s disbelief in reading these examples. It is difficult to read about a technique that Salomonsson himself admits must involve a personal responsiveness to the preverbal, in baby, mother, and clinician alike. It’s rather like saying, “You had to be there.” But as some of his treatments have in fact been taped, it would be pedagogically useful if students of this work could view them; perhaps a reissue of the book could include a CD so we could see something of the work for ourselves. At this point, in simply reading about it, one has the slightly disjunctive experience of continually wondering how speaking to a baby directly about words and situations an infant cannot developmentally understand can have such a salubrious effect. Salomonsson attests that it is through our unique psychoanalytic techniques (e.g., sensitivity to countertransference, continuous exposure to a dyad with frequent meetings within a psychoanalytic frame) that one can see the minute interactions that may be contributing to images and representations in an infant experience that will be hard to fathom once language comes on board, yet which is somehow expressed (and resonated with) by the carefully chosen, affectively laden words of the analyst.
Salomonsson, relying heavily on Bion’s concept of containment, insists it is the parent-infant analyst’s mandate to be a container, one whose very interventions as a participant observer can change the outcome of an early relationship. Here he is with three-month-old Frida: “But do you know something, little one: you are gone from Mum . . . because a while ago you didn’t look into her eyes. It was as if you took revenge on Mum. I understand that. It’s like when Mum didn’t look into my eyes yesterday. I had to ask her, ‘Hello Kate, why didn’t you say anything, could we get into contact?’” (p. 56). Yet Salomonsson is careful to tell us that in no way does he believe a baby so young can understand the lexical aspect of his words; it is the affective tone that counts, the emotional reverberations that “speak” to an infant during moments where both mother and infant have “uncontained” distress. Through attending to his countertransferences to both mother and baby, separately and together, Salomonsson feels he can ameliorate many early dilemmas.
He takes great pains to discuss how language and symbolization map onto a backdrop of nonverbal sensory experience present from the first days of life. He believes that like “Babushka dolls” (p. 92) early representations always form a core that nests within later, readily symbolizable experiences, particularly those our mothers were unable to “contain,” leaving them unmetabolized. He notes that we can sometimes get a feeling for this kind of “material” with adult patients in analysis, for example, those whose movements or grimaces are unknown to them, but salient to the analyst. The book is replete with vignettes from the consulting room, and we meet a variety of very, very young patients whom he tends to circle back to throughout the book. He tells us that these infants have functioned as his “supervisors,” helping him understand affects that may have undergone primal repression.
Even more controversial than directly addressing the baby is Salomonsson’s contention that an infant can form a transference to the analyst. Again, until he carefully walks us through his thinking, this too sounds somewhat phantasmagoric. He believes that it is indeed possible for a baby to have a transference, which can manifest itself in such phenomena as a sudden negative response to the analyst, as when a baby will not look at him, or, more positively, will gaze at him and not look at its mother in the session. Using his countertransference, Salomonsson attempts to contain and interpret what might be going on in these minute interactions. Unlike parent-infant therapists who examine a parent’s projections or attributions to the infant (“ghosts” in Fraiberg’s terminology), Salomonsson joins in the preverbal dance between mother and baby (he tells us he is an amateur musician, and one of his early papers was on affects and music); he uses his status as both outsider and insider, as well as his identifications with both mother and infant, to determine his interventions. He uses a lovely musical metaphor, that of being part of a chamber music trio, to describe the optimal role of the analyst in parent-infant treatment (p. 52).
There is no question that Salomonsson covers more ground than is probably necessary in one volume. Digressions include a chapter on the origins of infantile sexuality in the early dyad, and another in which he uses the story of Tristan and Isolde to illustrate his concept of the “living fossil.” The latter seems the least convincing and most truly speculative chapter in the book, with the author looking at a fictional character as if he were one of his patients.
Despite this, however, the book is an heroic effort to integrate and synthesize an enormous amount of theory and apply it to a type of practice that is unique and highly innovative. This volume is no primer. Nor is it just a book on theory. In fact, Psychoanalytic Therapy with Infants and Parents might have benefited from being divided up into several intersecting monographs (perhaps that’s what they were originally) without the need to weave them together into a unitary whole. That said, I look forward to reading more from this author, whose work will impress readers both with its clinical details and its concentric circles of psychoanalytic application. Yet at the end of the day, it is not exactly the vignettes that most impress, nor the theory he uses to elucidate and buttress his technique; rather, it is Salomonsson’s commitment to understanding how the earliest representations and incipient transferences come into being. This book seems a beginning, a work in progress, a workshop for a new theory that involves both baby and bathwater; it makes the point that we must never throw out either! Salomonsson urges us to think long and hard about infancy and how minds come to be constructed and co-created through the crucible of our earliest interactions.
Though our field has a long history, only recently have we become privy to the “living laboratory” of infancy; thus, those who work with parent-infant dyads are today in a uniquely privileged position to weigh in on how thought comes about and how the layers of the mind are laid down. We surely do not know how this happens yet, and at times Salomonsson’s seeming certainty can be irritating and provocative. But a close reading of the book indicates that he is not certain at all; he is working “in the belly of the beast,” very involved, very curious, and making some initial passes in a region where few psychoanalysts have personally ventured. For this Herculean effort alone we must respect him and read him carefully.